Standards and evidence-based guidelines

Standards are explicit statements of expected quality in the performance of a health care activity. They may take the form of procedures, clinical practice guidelines, treatment protocols, critical paths, algorithms, or standard operating procedures, among other formats (Ashton 2001).

Standards communicate expectations for how a particular health care activity will be performed to achieve the desired results and define, for both health workers and clients, what is needed to produce quality services. Standards are thus the cornerstone of most health care improvement approaches, including audit and feedback, accreditation, process improvement , and collaborative improvement.

In fields like health care that are continuously evolving with the development of new technologies, drugs, and procedures and that have an enormous body of scientific evidence available to support clinical decision-making, ensuring that standards are regularly updated, communicated to providers, and evidence-based is critical in assuring health care effectiveness and outcomes.

Adherence to evidence-based standards has been shown to be associated with improved health outcomes; moreover, failure to provide clinical care in accordance with standards has serious negative effects on patient outcomes.

To achieve expected health outcomes, standards must be clearly presented, achievable, and available to health care workers. While the MOH is the body that issues official standards for health services, often standards are not well communicated to frontline health workers or non-governmental organizations working in the health sectors. Ensuring that standards are achievable in the health care setting where they are to be applied is particularly important; standards must be locally appropriate and reflect both the expected competencies of health care providers in that setting, as well as the equipment, drugs, and supplies available to them. But even when locally appropriate, evidence-based standards exist, health workers may not follow them routinely, suggesting that standards in and of themselves are not enough to produce quality care.

A substantial body of research on guidelines implementation suggests many reasons why standards-based performance is often difficult to achieve and sustain. At the most basic level, health workers simply may not be familiar with standards because these have not been clearly communicated. In other cases, systemic factors, such as a lack of the necessary supplies or equipment to perform according to standards, delayed dissemination of standards from national to facility levels, poor monitoring and evaluation of guideline implementation, and a lack of human resources can affect implementation of standards. Motivating and enabling health workers to perform according to standards is one of the biggest challenges to producing quality health care (Rowe et al. 2005).

Health care professionals need to engage in educational opportunities to give them up-to-date knowledge and skills. Continuing medical education (CME) in the form of in-service training for physicians, nurses, and other health care workers has traditionally used short courses, conferences, seminars, medical rounds, small group sessions, workshops, tutorials, and other didactic methods to transfer clinical and other information to individuals and groups.

Numerous reviews, drawing primarily on studies in North America, have concluded that formal CME without support to enable or reinforce standards-based performance in actual practice has little or no impact on provider performance; however, when training events were complemented by other interventions to reinforce compliance, performance improvements were more likely to be demonstrated.

Despite the accumulated evidence pointing to the lack of effectiveness of traditional didactic training, expert-led teaching still prevails as the most common form of CME in developing and developed countries; however, the influence of adult learning theory on undergraduate and postgraduate medical education recently has resulted in increased interest in experiential learning methods and alternative educational formats and their application. These include inter-professional education, small group learning, learning contracts, telemedicine, and computer-based training.

USAID has invested considerable resources in improving the quality of in-service training for health care providers and supported the development of many online resources to strengthen the quality and effectiveness of training interventions. The Human Resources for Health Global Resource Center offers extensive resources related to education and training of health workers, covering continuing education, distance education, in-service training, pre-service education, and training methodologies.

With funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the USAID HCI Project facilitated a global process that engaged training program providers, professional and regulatory bodies, Ministries of Health, development partners, donors, and experts to develop and reach consensus on a set of practice recommendations to improve in-service training effectiveness, efficiency, and sustainability. The resulting Global Improvement Framework for Health Worker In-service Training provides guidance to training program providers, professional associations, and regulatory bodies on what practices are important to improve sustainability, effectiveness, and efficiency of in-service training to develop and maintain health worker competencies (ASSIST 2014). A related tool is the Training Evaluation Framework and Tools developed by the International Training and Education Center for Health, University of Washington, to help evaluators, implementers, and program managers at all levels plan successful evaluations of in-service training program outcomes.

Key Resources on Health Worker Education and Training